Placement of endobronchial valves for bronchopleural fistula (BPF) is not always straightforward. A simple guide to the steps for an uncomplicated procedure does not encompass pitfalls that need to be understood and overcome to maximize the efficacy of this modality. The objective of this study was to discuss examples of difficult cases for which the placement of endobronchial valves was not straightforward and required alterations in the usual basic steps. Subsequently, we aimed to provide guiding principles for a successful procedure. Six illustrative cases were selected to demonstrate issues that can arise during endobronchial valve placement. In each case, a real or apparent lack of decrease in airflow through a BPF was diagnosed and addressed. We have used the selected problem cases to illustrate principles, with the goal of helping to increase the success rate for endobronchial valve placement in the treatment of BPF. This series demonstrates issues that complicate effective placement of endobronchial valves for BPF. These issues form the basis for troubleshooting steps that complement the basic procedural steps.
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